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Antibiotic prophylaxis in cataract surgery in the setting of penicillin allergy: a decision-making algorithm

Poster Details

First Author: B.LaHood NEW ZEALAND

Co Author(s):    N. Andrew   M. Goggin                 

Abstract Details


Ophthalmologists are often faced with the dilemma of choosing appropriate antibiotic prophylaxis for patients undergoing cataract surgery who report a history of penicillin allergy. Recent findings that impact on this decision include an increasing body of evidence for the use of intracameral antibiotic prophylaxis; emerging safety concerns for intracameral vancomycin; and mounting pressure on all health practitioners to control the development of antibiotic-resistant organisms. This study aimed to assess the options for antibiotic prophylaxis in cataract surgery in the setting of penicillin allergy and provide an evidence-based algorithm to assist decision making in this area.


The Ophthalmology Department of the Queen Elizabeth Hospital and The University of Adelaide, Adelaide, Australia.


A literature search was conducted on the MEDLINE and EMBASE databases using the search terms ‘antibiotic’, ‘prophylaxis’, ‘cataract’, ‘phacoemulsification’, and ‘endophthalmitis’. Cited publications were examined to find additional articles of relevance. Select articles published before 1990 are included for historical purposes, but the algorithm was based mainly on articles published in the past decade. We included relevant case reports reporting on rare complications where case series or larger studies were unavailable. In total, 91 published resources were analysed. The subsequent algorithm was then applied in our facility and analysed prospectively for the past two years.


Current evidence supports administering intracameral cefuroxime if the history of penicillin allergy is considered low risk or questionable. Intracameral cephazolin may be safely substituted if necessary. With a more definite history of penicillin allergy, it may still be reasonable to administer intracameral cefuroxime, as the likelihood of cross-reaction is very small. Intracameral moxifloxacin appears the safest evidence-based alternative and we advise avoiding intracameral vancomycin. If necessary, immediate instillation of topical ofloxacin is our next ranked alternative. This evidence based algorithm has been used successfully in our facility for two years without a case of endophthalmitis or anaphylaxis.


Choosing antibiotic prophylaxis in patients with penicillin allergy is stressful and may have medicolegal implications. Evolving safety data for many commonly used agents as well as limited numbers of randomised, prospective studies makes this area of decision making both dynamic and complex. Having to make important decisions in the operating theatre can be stressful and therefore we encourage ophthalmologists to develop a protocol that is appropriate for their individual environment. This algorithm may serve as a framework to guide this process as it has proven to be safe and effective in our facility.

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